MEDICAL

The Denver Health Medicaid Choice preauthorization process helps members get the most successful health care treatment possible through:

• the right care
• from the right provider
• at the right time
• in the right setting

The treating doctor is responsible to ask for authorization for certain tests and treatments. Denver Health Medicaid Choice staff will tell you in writing exactly what services are approved. Call Denver Health Medicaid Choice Customer Service at 720-956-2100 to ask about the preauthorization process or to get benefit quotations.

 

Prior Authorization is required for, but not limited to, the following services:

• Durable medical equipment
• Genetic testing
• Home health care, including IV therapy
• All hospital stays, including alcohol or substance abuse-related stay
• Outpatient surgery, except those procedures performed in a physician’s office
• Prescription drugs that require prior authorization as listed in the DHMP formulary
• Renal dialysis
• Skilled nursing facilities
• Transplant evaluations and procedures
• Hospice

IMPORTANT:

The preauthorization list is updated periodically and subject to change. Failure to get preauthorization may result in nonpayment for the services, and the member cannot be balance billed.

How to Submit a Preauthorization Request

• Fax preauthorization requests as soon as you are aware the member requires services that need to be preauthorized.  Fax to 
• Also fax clinical notes with the request for review.
• If you are directing a member to a noncontracted provider, submit a request for authorization before any service is provided.
• The forms for requesting preauthorization must have all required fields completed, including applicable ICD, CPT, and/or HCPC codes.

Medical Preauthorization Forms

Click on the links below to download preauthorization request forms:

DME Prior Authorization form
Home Health Prior Authorization form
Medical Necessity Prior Authorization form

Notification of Admission

The admitting facility is responsible to notify Denver Health Medicaid Choice of an inpatient or observation admission within twenty four (24) hours of admission, unless a weekend or holiday is involved, in which case notification must occur the first business day following the weekend or holiday.

Denver Health Medicaid Choice covers a wide variety of medications. The Denver Health Medicaid Choice Formulary Guidelines include information about Denver Health Medicaid Choice drug coverage. Denver Health Medicaid Choice drug coverage is determined with active participation from an Denver Health Medicaid Choice physician/pharmacy committee.

Denver Health Medicaid Choice Formulary Guidelines:

• Include the coverage level for certain drugs (prior authorization, covered at what copayment tier, covered for what quantity of medication, not covered, etc.)
• Encourage the use of appropriate generic drugs
• Are updated regularly

Click here to see the

Medicaid Choice Formulary

Prescription Drugs Requiring Care Management Approval

Certain drugs are preauthorized by CM. 

Brand Name Accutane     Adderall (>21 years of age)     Adderall XR     Aranesp     Arava     Avonex    Betaseron     Celebrex     Cellcept     Copaxone     DDAVP     Dexedrine (>21 years of age)     Dexedrine Spansule (>21 years of age)     Dovonex     Enbrel     Estraderm    Humira     Imitrex     Kytril     Lamictal    Lamisil     Leukine    Lovenox     Miacalcin     Neupogen    Nutropin, Nutropin AQ     Procrit     Prograf     Pulmicort Respules (>8 years of age)     Pulmozyme     Regranex     Retin-A (>39 years of age)     Ritalin (>21 years of age)    Ritalin LA, Concerta, Metadate CD     Ritalin SR (>21 years of age)     Rythmol     Soriatane    Sporanox     Tambocor     Viagra     Zofran     Zyprexa

Generic Name isotretinoin amphetamine/ dextroamphetamine mixed salts amphetamine/ dextroamphetamine mixed salts ext-rel darbepoetin alfa leflunomide interferon beta-1a interferon beta-1b celecoxib mycophenolate mofetil glatiramer desmopressin Dextroamphetamine  Dextroamphetamine ext-rel calcipotriene etanercept estradiol transdermal adalimumab sumatriptan injection granisetron lamotrigine terbinafine sargramostim enoxaparin calcitonin-salmon nasal, injection filgrastim somatropin epoetin alpha tacrolimus budesonide dornase alfa becaplermin tretinoin methylphenidate (immediate release) methylphenidate ext-rel methylphenidate ext-rel propafenone acitretin itraconazole caps flecainide sildenafil ondansetron olanzapine

For Prior Authorization (PA) drugs, the prescribing physician should fax the Pharmacy Drug Request Form to (720) 956-2303 with the clinical information regarding the necessity of the drug. If you have any questions, call Medical Services at (720) 956-2302. If a pharmacist receives a rejection message indicating Prior Authorization required, they should contact the prescriber to have the prescription changed to an alternative Formulary medication. If the prescriber does not feel this is in the best interest of the patient they may request a medical exception using the Pharmacy Drug Request Form described above. 

The Medical Director will review the request and will either approve the request, recommend a therapeutic formulary alternative, or deny the request. The requesting prescriber will be notified of the decision within 72 hours. An expedited review for urgent situations can be requested.

If the request is denied, the prescriber and the patient will be notified of the process for requesting a reconsideration by the reviewer who made the decision. They will also be notified of the appeal process.

All initial authorizations for PA or non-formulary medication from a prior insurance provider will be placed in the system for a limited period (usually 2 months) which will allow the ordering physician time to prescribe a formulary drug for the patient. If the physician wishes an extension of the initial authorization, he/she should notify the pharmacy case manager at (720) 956-2302. The Pharmacy Case Manager will review the request with the Medical Director, and if approved, will place an authorization in the system for an appropriate period of time up to one year. Extensions of authorizations after a year will require the PCP or ordering physician to review and complete a new Pharmacy Drug Request Form. This will indicate a review of the patient status on the medication including any pertinent lab results.

Drug Authorization Form

Behavioral

Psychiatric Drub Authorization Form